The Role of Injectables in Aesthetic Surgery: Financial Implications.

Background: The plastic surgeon competes with both core and noncore physicians and surgeons for traditional cosmetic procedures. In 2007, the American Society for Aesthetic Plastic Surgery (ASAPS) and the American Society of Plastic Surgeons (ASPS) joined efforts to form a Cosmetic Medicine Task Force to further analyze this trend. Objectives: Our objective is to document and quantify the patient capture and total collections generated in a single surgeon's practice exclusive from Botulinum Toxin A and filler injections over a 10-year period. We subsequently identified the effect and importance that fillers and Botulinum Toxin A have on an active cosmetic practice. Methods: A retrospective chart review of all male and female patients who received Botulinum Toxin A or soft tissue filler injections (noninvasive aesthetic treatment) in a single surgeons practice from January 2004 to December 2013 was undertaken. Only those patients new to the practice and who were exclusively seeking out Botulinum Toxin A or fillers were included in the study. Chart review then identified which of these selected patients ultimately underwent invasive aesthetic surgery during this 10-year period. Noninvasive and invasive aesthetic surgery total collections were calculated using billing records. Results: From January 2004 to December 2013, 375 patients entered the senior surgeon's practice specifically requesting and receiving noninvasive aesthetic treatments. Of these 375 patients, 59 patients (15.7%) subsequently underwent an aesthetic surgery procedure at an average of 19 months following initial noninvasive aesthetic treatment. Of these 375 patients, 369 were female and 6 were male. The most common initial invasive aesthetic procedure performed after injectable treatment included 22 facelifts (18.5%), 21 upper eyelid blepharoplasties (17.6%), and 15 endoscopic brow lifts (12.6%). Total collections from noninvasive aesthetic sessions and invasive surgery combined represented US$762,470 over this 10-year span. This represented US$524,771 and US$396,166 in total collections for injectables and surgery respectively. Conclusions: Noninvasive aesthetic surgery is a critical part of a plastic surgery practice. A measurable and significant number of patients who sought out a single plastic surgeon exclusively for noninvasive treatment ultimately underwent traditional invasive cosmetic surgical procedures.

Objective Assessment of Facial Rejuvenation After Massive Weight Loss.

BACKGROUND: While the literature is replete with articles about body contouring after bariatric surgery, little information exists regarding the outcomes of facelift following massive weight loss (MWL). A case report and a technique article are the only sources available addressing this issue. This pilot study objectively examines the effects of MWL in the cervicofacial region and results after facelift. METHODS: A retrospective review of seven patients who underwent facelift after MWL (>100 pounds) was performed. Patient's change in appearance was objectively evaluated using an apparent age model. Forty blinded reviewers assessed pre- and postoperative photographs of seven MWL and eleven non-MWL female patients. The reviewers estimated the apparent age for each subject. Reduction in apparent age was calculated by comparing patient's apparent age against actual age. RESULTS: The preoperative apparent age of MWL patients was 5.1 years older than their actual age (p < 0.02) compared to the increased preoperative apparent age of 1.2 years in non-MWL subjects (p > 0.05); suggesting MWL patients appear older than their actual age. Post-operatively, the apparent age reduction in MWL patients was 6.0 years; and their apparent age after surgery was 0.9 year less than their actual age (p > 0.05). In contrast, the control group exhibited an apparent age reduction of 5.4 years and a postoperative apparent age 4.2 years younger than their actual age (p < 0.01). Apparent age reduction was not significantly different for the two groups (p > 0.05). Age, BMI, and follow-up were similar between groups (p > 0.05). CONCLUSIONS: MWL may accelerate apparent cervicofacial aging. Facelift following MWL enhances cervicofacial appearance and significantly reduces apparent age. We hope this study stimulates further interest in the study of facial esthetics in this increasing population. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Is ketorolac safe to use in plastic surgery? A critical review.

BACKGROUND: Ketorolac tromethamine is a nonsteroidal anti-inflammatory drug (NSAID) that provides postoperative pain control and reduces narcotic requirements. However, concerns regarding postoperative hematoma have limited its use in plastic surgery. OBJECTIVES: Our goal is to critically review the risk of bleeding with ketorolac in plastic surgery patients, with a focus on aesthetic surgery. METHODS: A PubMed/Medline literature search of clinical trials using the keywords "surgery" and "NSAID" yielded 2574 results. Of these results, 1036 included ketorolac and twelve involved plastic surgery patients. Six studies reported postoperative hematoma rates: three prospective randomized trials, two retrospective reviews, and one case series. These were subjected to statistical analysis to determine if an association existed between ketorolac and postoperative hematomas. RESULTS: Six papers reported 981 cases. Ketorolac use resulted in similar hematoma rates when compared to control groups, 2.5% (12 of 483) versus 2.4% (12 of 498), respectively (P = .79). There were no reported hematomas associated with ketorolac in over 115 patients undergoing aesthetic facial procedures. Hematoma rates of those undergoing aesthetic breast surgery, including reduction and augmentation mammoplasties, were 4.3% (11 of 257) in the ketorolac group versus 2.2% (6 of 277) in controls (P = .59). Reduction in postoperative narcotic use and improved pain scores was also reported. CONCLUSIONS: Our literature review did not find a significant association between hematoma formation and ketorolac use in a variety of plastic surgery procedures. These findings are similar to those in other surgical subspecialties.

Putting it all together: recommendations for improving pain management in plastic surgical procedures-surgical facial rejuvenation.

BACKGROUND: Postoperative pain is a major concern for patients undergoing facial aesthetic surgery. Aggressive efforts to reduce postoperative pain while avoiding adverse sequelae, such as nausea and vomiting, will result in an improved patient experience. Newer pharmaceuticals, medical devices, and longer-acting local anesthetics offer the potential to reduce pain and enhance patient satisfaction. The purpose of this report is to review the options and apply them to 3 specific facial aesthetic procedures: face-lift, brow lift, and blepharoplasty. METHODS: Our review investigates methods used for pain control in the surgical facial rejuvenation patient. We highlight those techniques that have been documented efficacy. We share specific methods of pain management for the more common surgical facial rejuvenation procedures that we perform. RESULTS: In an effort to maximize patient comfort, we assess the effectiveness of various devices, technologies, and treatment modalities available for pain control after surgical facial rejuvenation. These include local anesthetics, topical creams, intravenous acetaminophen, perioperative ketorolac, local anesthetic wound catheter delivery systems, liposomal bupivacaine, tarsorrhaphy/frost sutures, postoperative pharmacologic therapeutics, prophylactic steroids, and tricks to eliminate pain with suture removal. Additionally, we summarize the primary investigator's preferred method of pain management for the common surgical facial rejuvenation procedures performed. CONCLUSIONS: Recent advances in postoperative pain control can significantly improve the patient's surgical experience. This multimodal therapy includes new pharmaceuticals, longer-acting local anesthetics, and devices designed to minimize postoperative pain. Adoption of these techniques may also reduce the need for narcotics and prevent postoperative adverse sequelae.

Skin sterility after application of a vapocoolant spray.

BACKGROUND: Refrigerant sprays have been widely used to reduce pain in the office setting. However, more recently, their use has been limited by both concern regarding flammability and questions of bacterial contamination. OBJECTIVE: We investigated the microbiological effect of 1,1,1,3,3 pentafluoropropane and 1,1,1,2-tetrafluoroethane when sprayed after povidone-iodine application in 50 volunteers. MATERIALS AND METHODS: In 50 volunteers, 3 cultures were taken (1) at time 0 before antiseptic application, (2) after povidone-iodine topical antiseptic, and (3) after spraying with vapocoolant. Cultures at 3 time intervals were analyzed in a blinded fashion, and Gram stains obtained when cultures were positive. RESULTS: Bacterial growth was found in 98% of cultures taken before antiseptic was applied (Group 1), in 28 cultures (56%) after povidone-iodine was applied, and in 24 cultures (48%) after spraying with vapocoolant. There was a statistically significant difference found between Group 1 (no antiseptic) and both Group 2 (after antiseptic but before vapocoolant) and Group 3 (after vapocoolant) (p < .001). CONCLUSION: The topical antiseptic povidone-iodine significantly reduces skin colonization when compared with unprepared skin (p < .001). The vapocoolant 1,1,1,3,3 pentafluoropropane and 1,1,1,2-tetrafluoroethane is sprayed on skin prepared with povidone-iodine; there is no statistically significant increase in bacterial colonization.

Surgical adhesive increases burst pressure and seals leaks in stapled gastrojejunostomy.

BACKGROUND: Leakage from a gastrointestinal anastomosis in bariatric surgery is a catastrophic complication and is the second-most preventable cause of death after Roux-en-Y gastric bypass. Several adjuncts for staple line reinforcement have been investigated to reduce the incidence of this complication. The purpose of our study was to determine whether a commercially available tissue sealant (BioGlue) could reinforce a stapled gastrojejunal anastomosis and whether it could seal an artificially created anastomotic leak. METHODS: Circular-stapled gastrojejunostomies were performed on freshly explanted porcine stomach and intestine. Experiment 1 consisted of 10 control nonreinforced gastrojejunostomies and 10 gastrojejunostomies reinforced with BioGlue. The staple lines were submerged in saline and exposed to increased pressure using constant-rate infusion of air. The burst pressures were recorded at the point of visible leakage from the anastomosis. In experiment 2, a small defect was created in 10 gastrojejunostomies. The burst pressures were recorded before and after application of BioGlue to the anastomosis. The data were analyzed using the 2-tailed paired t test. RESULTS: In experiment 1, the burst pressure was significantly increased in the reinforced gastrojejunostomies, from 27.4 ± 8.4 mm Hg to 59.1 ± 19.2 mm Hg (P <.001). In experiment 2, the defective gastrojejunostomies had an average burst pressure of 1.2 ± 0.8 mm Hg. After application of BioGlue, the burst pressure increased to 42.8 ± 15.9 mm Hg (P <.001). CONCLUSION: These ex vivo findings suggest that the surgical adhesive BioGlue can reinforce both intact and defective stapled gastrojejunal anastomoses. Additional in vivo study is warranted to determine whether BioGlue can prevent or help seal gastrojejunal leaks.

Quantitative effects of tumescent infiltration and bupivicaine injection in decreasing postoperative pain in submuscular breast augmentation.

BACKGROUND: In submuscular breast augmentation, the muscle is transected along its inferior and medial border to allow the implant to rest beneath the breast mound and supply adequate cleavage. This leads to significant pain in the postoperative period. OBJECTIVE: This study was undertaken to quantitatively document the effectiveness of tumescent infiltration and bupivicaine with epinephrine injection in controlling postoperative pain in primary submuscular breast augmentation and its effect on operating time, narcotic use, and complications. METHODS: A retrospective chart review of 150 primary submuscular augmentation mammaplasties performed by 2 surgeons was conducted. Seventy-five consecutive augmentations performed by each physician during the same time period were studied. One surgeon used tumescent infiltration, using a syringe and a blunt infiltration cannula, placing 50 mL of standard tumescent solution in the planned pocket area of each breast before dissection. In addition, all cut muscle ends were injected with 0.25% bupivicaine with epinephrine (1:100,000, 40 mL per patient) under direct vision. The other surgeon omitted these steps. Patients evaluated pain subjectively using a 0 to 10 numeric pain intensity scale reported to the recovery room staff at specific times in the postanesthesia care unit. RESULTS: Postoperatively, the initial and discharge average pain rating was significantly different between the groups. The group that received tumescence and bupivicaine with epinephrine entered the recovery room with a significantly lower average pain score: 0.5 as compared with the pain score of the control group, which was on average 3.3. In addition, the highest average pain rating was 2.6 in the infiltrated group compared with 5.4 in the noninfiltrated group. Pain at discharge between the groups was also seen to be markedly lower with a subjective average rating of 2.0 in the infiltrated group compared with 4.0 in the control group. No difference was seen in operative time or complications. CONCLUSIONS: This is the first report to quantitatively show a pain reduction regimen that is effective in significantly decreasing postoperative pain and decreasing the use of narcotics in the recovery room. The authors conclude that its advantages are significant, and they advocate its use in all breast augmentations.